Provider Demographics
NPI:1760543375
Name:PHELAN, TIMOTHY EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:EDWIN
Last Name:PHELAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 CREEKSIDE DR
Mailing Address - Street 2:102
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3493
Mailing Address - Country:US
Mailing Address - Phone:916-984-7428
Mailing Address - Fax:
Practice Address - Street 1:1621 CREEKSIDE DR
Practice Address - Street 2:102
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3493
Practice Address - Country:US
Practice Address - Phone:916-984-7428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG084901207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG084901OtherCA LICENSE NUMBER
CA00G849011OtherMEDICAL PROVIDER NUMBER
CA00G849010Medicare ID - Type Unspecified
CA00G849011OtherMEDICAL PROVIDER NUMBER